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MSc in Clinical Psychology
The Relationship Between Anxiety and Depression Symptoms,
and Help-Seeking Intentions in Individual Sport Athletes and
University Students in Iceland:
The Moderating Role of Gender and Participant Status
June 2017
Name: Richard Eiríkur Taehtinen
ID number: 050781-2329
Supervisor: Hafrún Kristjánsdóttir
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 2
Foreword and Acknowledgements
This MSc thesis was conducted in partial fulfillment of the requirements for the degree of
Master of Science in Clinical Psychology at Reykjavik University, and will be submitted for
publication in The Journal of Clinical Sport Psychology. The co-author for the submission will
be the main supervisor of this thesis, Dr. Hafrún Kristjánsdóttir.
This thesis paper is the result of a research project that was initiated in the beginning of
the spring semester of 2016, and was conducted across three consecutive semesters as part of a
MSc thesis course. The main coordinator of the MSc thesis course was Professor Jón Friðrik
Sigurðsson. Within this course, specific assignments were due by the end of each semester
including; a research plan, a literature review, an application (and approval of the application) to
the Icelandic bioethics committee, a draft of the thesis methods and results, and the final
submission of the MSc thesis.
Throughout this project, it became increasingly apparent to me that mental health issues
among Icelandic athletes and university students warrant more attention. My sincere hope is that
this thesis can motivate relevant stakeholders to take mark of this need. The National Olympic
and Sports Association of Iceland and the Universities, and the athletes and the university
students that participated in this study deserve a special thank you. I want to thank my
supervisor, Dr. Hafrún Kristjánsdóttir for her support and assistance throughout this project. I
also want to express my gratitude to the faculty members at the Psychology department at
Reykjavik University for their help and support during the past five years of my studies. And to
Rósa, you have been the backbone in everything, thank you!
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 3
Abstract
This study explored the relationship between anxiety and depression symptoms, and
intentions to seek professional help from psychologist, and the moderating role of gender and
participant status in this relationship. A total of 375 University students and 187 individual sport
athletes, 18 years and older were included in the study.
A significant main effect of symptoms on help-seeking intentions was observed among
females and this was moderated by participant status; female athletes with depression symptoms
reported lower intentions than female students with depression symptoms. There was no main
effect of symptoms among athletes, but a significant cross-over interaction effect of symptoms
and gender on intentions was observed; non-symptomatic female athletes reported higher
intentions than male athletes without symptoms, and female athletes with depression symptoms
reported lower intentions than male athletes with depression symptoms.
Results suggested that experiencing depression symptoms may decrease female athletes’
intentions to seek help from psychologist.
Keywords; anxiety, depression, help-seeking intentions, athletes, university students
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 4
Organized youth sports are thought to prepare individuals for life through positive
physical and psychosocial development (Eime, Young, Harvey, Charity, & Payne, 2013).
However, despite of the potential benefits acquired through youth sports, as athletes transition
into senior sports, health related risk factors may become more prominent (Rice, Purcell, De
Silva, et al., 2016). It is not until recently however that the prevalence of common mental
disorders (CMD), such as anxiety and depression, has been systematically explored among the
athlete populations. The current literature indicates that prevalence of CMDs among athletes may
vary depending on sport-specific factors and that some athlete groups may be more vulnerable to
mental health problems than others (Gulliver, Griffiths, Mackinnon, Batterham, & Stanimirovic,
2015; Rice, Purcell, Silva, et al., 2016; Roberts, Faull, & Tod, 2016; Weigand, Cohen, &
Merenstein, 2013). For example, one consistent finding has been that individual sport athletes
may be at a higher risk for CMDs than team sport athletes (Nixdorf, Frank, & Beckmann, 2016;
Nixdorf, Frank, Hautzinger, & Beckmann, 2013; Schaal et al., 2011; Wolanin, Hong, Marks,
Panchoo, & Gross, 2016). However, there is a need to explore this athlete population in more
detail as most studies to-date have assessed CMDs in relatively small samples and/or within a
limited range of different individual sports. For example, a study by Hammond, Gialloreto,
Kubas, and Davis IV (2013) assessed depression symptoms in athletes from only one sport
(swimming). Gulliver et al. (2015) assessed multiple mental disorders and only 15 individual
sport athletes were included, representing only two different sports (rowing and sailing). One
study assessed depression symptoms in individual sport athletes from 10 different individual
sports, however, the sample size was relatively small (n = 59) (Nixdorf et al., 2013).
Furthermore, Wolanin et al. (2016) assessed depressive symptoms including individual sport
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 5
athletes from five different individual sports and the sample size was larger than observed in
other studies to-date (n = 127).
Previous studies have reported highly variable prevalence rates in athletes’ current
anxiety and/or depression symptoms, ranging from 6 % (Schaal et al., 2011) to 45%
(Gouttebarge, Backx, Aoki, & Kerkhoffs, 2015). These inconsistencies may be due to
differences in measurement and assessment methods, as well as due to differences in study
populations. For example, while some studies have assessed prevalence of CMDs among
European elite athletes through in-person interviews (Schaal et al., 2011), others have more
commonly utilized self-report measures (e.g. Nixdorf et al., 2013). Furthermore, while some
European and Australian studies have often compared elite or professional athletes’ to the
general population, showing similar prevalence rates between these groups (Gouttebarge, Backx,
Aoki, & Kerkhoffs, 2015; Nixdorf, Frank, Hautzinger, & Beckmann, 2013; Wolanin, Hong,
Marks, Panchoo, & Gross, 2016), other studies have assessed prevalence rates among North
American collegiate athletes and non-athletes, and reported lower prevalence rates in athletes
than non-athletes (Armstrong, Burcin, Bjerke, & Early, 2015; Armstrong & Oomen-Early,
2009). Despite of these methodological differences, the results from previous studies underline
the fact that athletes do experience mental health problems and that further studies among the
athlete population are warranted.
Although the question about athletes’ risk for CMDs compared to other population
groups is still a under debate, one question that is especially important from a treatment
perspective concerns athletes’ tendency to seek help when they experience mental health
symptoms. Hence, although it is important to acquire more knowledge about the prevalence of
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 6
CMDs within the athlete population, it is also important to understand which athletes may be in
an increased risk for not seeking help when symptoms emerge.
Help-seeking can be defined as a behavior where an individual expresses a need for help
by approaching informal (e.g. friends and family) or formal (e.g. psychologist) sources for help
(Rickwood, Deane, Wilson, & Ciarrochi, 2005). The help-seeking process involves the
identification of a need for help, a deliberate decision process to seek help (intention), and the
actual behavior of seeking help (Rickwood et al., 2005). Previous help-seeking experiences,
especially positive ones, may significantly increase individuals‘ intentions to seek help in the
future (Martin, 2005). However, for the majority of people, help-seeking from psychologists may
not represent a habitual behavior, and hence intentions may be an important marker for future
help-seeking behaviors (Ouellette & Wood, 1998).
Epidemiological studies have consistently reported that females are more likely than
males to experience mood and anxiety disorders (Nolen-Hoeksema & Girgus, 1994; Steel et al.,
2014). In contrast, studies suggest that males, of different ages, ethnicities, and social
backgrounds, are as less likely than females to seek help for mental health problems (Addis &
Mahalik, 2003). Similar gender differences have also been observed within the athlete population
in prevalence (Rice, Purcell, Silva, et al., 2016) and in help-seeking patterns (Martin et al.,
2001;Martin, Lavallee, Kellmann, & Page, 2004). Males’ overall lower tendency to seek help has
often been understood in terms of males’ socialization into masculine roles, and that these roles
are discrepant with the act of seeking help from others (Addis & Mahalik, 2003; Judd, Komiti, &
Jackson, 2008). This socialization process may be especially prevalent within the sport culture
where masking weakness (Gulliver, Griffiths, & Christensen, 2012) and exhibiting toughness,
and ignoring or downplaying injury may be highly valued (Martin, 2005; Steinfeldt, Steinfeldt,
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 7
England, & Speight, 2009). Subsequently, some previous studies have shown that athletes may
have less positives attitudes towards help-seeking than non-athletes (Watson, 2005).
Although these studies have expanded our understanding about how socialization through
and in sports may give rise to attitudes and beliefs that may hinder help-seeking, intentions to
seek help do not exist in a vacuum. That is, individuals’ intention to seek help may depend on the
type and severity of symptoms experienced, and it may be that those with the highest expected
need may report the lowest intention to seek help (Deane, Wilson, & Ciarrochi, 2001; Rickwood
et al., 2005; Wilson & Deane, 2010). For example, while increasing levels of depression
symptoms may relate to decreased help-seeking intentions, increasing levels of anxiety
symptoms may relate to increased intentions (Wilson & Deane, 2010). Furthermore, while
individuals with minimal symptoms may initially report intentions to seek help in the future, as
mental health symptoms emerge, intentions to seek help may decrease (Deane et al., 2001).
Hence, although studies have reported that athletes may report less positive attitudes towards
help-seeking than non-athletes (Watson, 2005), to the author’s knowledge no studies have
explored differences in athletes’ and non-athletes’ help-seeking intentions in conjunction to
current psychological symptoms.
In sum, only a few studies have assessed CMDs within an individual sport athlete sample
consisting of athletes from a range of different individual sports (for an overview see; Rice,
Purcell, Silva, et al., 2016), and these studies have not assessed how symptoms may influence
help-seeking intentions. In addition, much of the extant literature reporting prevalence rates of
CMDs and help-seeking patterns among athletes have been conducted in larger sporting nations,
where the contextual factors may have different implications for the athlete than in smaller
sporting nations such as in Iceland (Swann, Moran, & Piggott, 2015). Furthermore, as indicated
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 8
in a study by Martin, Lavallee, Kellmann, and Page (2004) attitudes towards sport psychology
consulting may vary not only as a function of type of sport and gender, but also as a function of
nationality. Hence, an increased understanding of the country-specific patterns of symptom
prevalence and how these symptoms relate to help-seeking intentions among Icelandic athletes is
important in order for local and national sport organizations, and other stakeholders, to develop
appropriate support and prevention strategies for in-risk athletes.
The first aim of the current study was to assess anxiety and depression symptoms, and
help-seeking intentions in Icelandic individual sport athletes and university students, and to test
if symptoms and help-seeking intentions differed depending on gender and participant status.
Based on the reviewed studies it was anticipated that males would report significantly lower
levels of anxiety and depression symptoms, and help-seeking intentions than females. It was also
expected that athletes would have lower help-seeking intentions than students. No, other
hypotheses were set forth due to inconsistencies in the current literature.
The second aim of this study was explorative in nature and aimed to extend current
knowledge by exploring the relationship between type of symptoms (i.e. no symptoms, anxiety
only, depression only, and comorbid anxiety and depression) and help-seeking intentions, and if
this relationship would be moderated by gender and/or participant status.
Methods
Participants
The athlete sample consisted of male (n = 85) and female (n = 97) athletes, competing at
the national and/or international level in any of the individual sports that are members of the
National Olympic and Sports Association of Iceland (Íþrótta og Ólympíusamband Íslands, ISI).
Inclusion criteria for athletes was; being 18 years or older, fluency in the Icelandic language, and
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 9
competing nationally or internationally in any of the individual sports that are members of the
National Olympic and Sports Association of Iceland. The comparison group consisted of male (n
= 101) and female (n = 270) university students currently enrolled in one of the seven Icelandic
Universities. Inclusion criteria for the comparison sample was being 18 years or older, being
fluent in the Icelandic language, and not currently competing in any sport.
Measures
Background variables. The online survey assessed demographic variables such as age,
gender, and previous help-seeking experiences. Age was assessed in categories (three age groups
per category e.g. 18-20) and previous help seeking was assessed with a multi-response scale
where respondents were asked if they had ever sought help from a psychologist. Response
categories were “yes, within the past 30 days”, “yes, within the past 12 months”, “yes, more than
12 months ago”, or “no”. Previous help seeking was then coded into a dichotomized variable
“yes” or “no”. Individual sport athletes also answered whether they were currently in the
national team or an elite training group.
General Anxiety Disorder 7 (GAD-7). Is a brief, 7-item self-report measure for
assessing generalized anxiety disorder but is also suitable for assessing symptoms of anxiety in
more general (Spitzer, Kroenke, Williams, & Löwe, 2006). The GAD-7 assesses symptom
frequency and the severity of those symptoms during the past two-weeks. Each item on the scale
is scored from 0 to 3, thus total score ranges from 0-21, with higher scores representing more
severe symptoms of anxiety and scores 10 or above are considered as clinically relevant. The
psychometric properties of GAD have shown to be good among the clinical (Spitzer et al., 2006)
and the general population abroad (Löwe et al., 2008) and in Iceland (Ingólfsdóttir, 2014). In the
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 10
current sample, reliability was shown to be very good (α = .90). Responses with more than 10 %
of missing values on the scale were not included.
Patient Health Questionnaire 9 (PHQ – 9). Is a nine-item self-report scale, that assesses
depressive symptoms during the past two-weeks. Each item is scored from 0 to three ranging
from “not at all” to “nearly every day”, thus total scores range from 0 to 27, with higher scores
representing more severe symptoms. Identical to the GAD-7, scores 10 or above are considered
as clinically relevant. The psychometric properties of PHQ-9 have shown to be good among the
clinical (Kroenke & Spitzer, 2002) and the general population (Martin, Rief, Klaiberg, &
Braehler, 2006) abroad, and in Iceland (Palsdottir, 2007). In the current sample, reliability was
shown to be very good (α = .87). Responses with more than 10 % of missing values on the scale
were not included.
Icelandic version of the Beliefs About Psychological Services (I-BAPS). Is an
Icelandic (cross-culturally validated) version of the 18-item self-report measure; Beliefs About
Psychological Services (BAPS, Aegisdottir & Gerstein, 2009). The I-BAPS is a 22-item
questionnaire containing three subscales; Intent, Stigma Tolerance, and Expertness with each
sub-scale score intended to be reported separately. The intent sub-scale was utilized in the
current study. The intent scale includes six positively worded statements such as “At some future
time, I might want to see a psychologist” or “I would see a psychologist if I were worried or
upset for a long period of time”. Each item range from one (strongly disagree) to six (strongly
agree) and the total scale score is calculated as the sum of each item response divided by the
number of items, with higher scores representing greater intentions or willingness to seek help
from a psychologist in the future. The I-BAPS was chosen for the current study as it is currently
the only measure of help-seeking intention that has been adapted in Iceland, and has shown good
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 11
psychometric properties among the Icelandic general population (Ægisdóttir & Einarsdóttir,
2012). Permission to utilize the scale was granted by the developers of the I-BAPS. In the current
study sample, reliability was shown to be very good (α = .87). Responses with more than 10 % of
missing values on the scale were not included.
Procedures
A non-probability (convenience) sampling method was utilized to recruit participants
competing in individual sports. Firstly, the author advertised the study on Facebook with a short
description of the study purpose, inclusion criteria, and providing a direct link to the online
questionnaire. Individual athletes currently in elite or national team programs, were directly
contacted through Facebook or indirectly through their coaches and requested to answer the
online questionnaire. Furthermore, with help from The National Olympic and Sports
Association, all individual Sport Federations were contacted and requested to forward a link to
the online questionnaire to relevant athletes (i.e. 18 years and older, fluent in Icelandic, and
actively competing in an individual sport at national or international level).
A non-probability (convenience) sampling method was also utilized to recruit the
university sample. Firstly, the authors advertised the study on Facebook with a short description
of the study purpose, inclusion criteria, and providing a direct link to the online questionnaire.
Furthermore, all Icelandic Universities were contacted and requested to cooperate. Universities
that agreed to cooperate (six out of seven), advertised the study on their respective internal webs
and/or sent out emails to all students with a short description of the study purpose and a link to
the survey.
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 12
Statistical Analyses
For anxiety and depression symptoms, participants were dichotomized into clinically
relevant or no clinically relevant symptom-groups. Clinical relevance was defined as scores 10 or
above for both depression (Kroenke & Spitzer, 2002) and anxiety symptoms (Spitzer, Kroenke,
Williams, & Löwe, 2006). Column proportions were then compared between athletes and
students utilizing Pearson’s chi square to test for significant differences in prevalence between
groups.
To test how participant status (athlete vs. student) and gender was related to the
dependent variables anxiety and depression symptoms, and help-seeking intentions, separate 2
(participant status) x 2 (gender) Factorial ANOVAs were conducted for each dependent variable.
When testing help-seeking intentions, age and previous help-seeking from psychologist were
included as covariates. When testing for anxiety and depression symptoms, only age was
included as a covariate. Since the homogeneity of variance assumption was violated for anxiety
and depression symptoms, a square root transformation was executed for these dependent
variables. However, analyses with transformed data did not influence the results, and hence the
original analyzes are reported.
To explore the moderation effect of gender and participant status on the relationship
between symptoms and help-seeking intentions, participants were categorized based on their
clinically relevant symptoms; no symptoms, anxiety only, depression only, and comorbid
depression and anxiety. A 2 (participant status) x 4 (symptom type) model was conducted
separately for females and males to test the moderating effect of participant status on the
relationship between symptoms and help-seeking intentions.
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 13
A 2 (gender) x 4 (symptom type) model was conducted separately for students and
athletes to test the moderating effect of gender on the relationship between symptoms and help-
seeking intentions. In all moderation models, help-seeking intention scale score was the
dependent variable, and age and previous help-seeking from psychologist were included as
covariates. The assumption of homogeneity of variance was not violated. All analyses were
conducted with IBM statistics SPSS software version 24.
Ethical Considerations
Participants received information about the study purpose and its anonymity on the
introduction page of the online questionnaire. Participants were informed that participation was
voluntary and that participation could be withdrawn at any point during the study. Data was
merely accessible to the primary investigator and the supervisor of the study, and was stored on a
private password-protected folder. Considering the small population in Iceland, the athlete
questionnaire was designed in such a way that identification of individual athletes was not
possible. This study was approved by the Icelandic Bioethics Committee (application number
16-148).
Results
Descriptive Analyses
As shown in table 1, the athlete sample had a higher proportion of participants in the age
ranges 18-20 years of age (30.8 %) than the student sample (8.2 %). Students also reported more
experience of seeking help from a psychologist at some point in their lives (55.0 %) than athletes
(39.3 %). Among athletes, 75.0 % were currently in the national team or in an elite training
group. Athletes competed in a range of different sports including racquet sports (tennis,
badminton, and table tennis), precision sports (golf, bowling, and shooting sports), aesthetic
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 14
sports (gymnastics, figure skating, and dance), speed and conditioning sports (track and field and
swimming), combat sports (Judo, karate, boxing, Taekwondo, and wrestling) and power sports
(powerlifting and Olympic weightlifting). A total of 35 athletes did not specify their sport or
their sport did not fall specifically under any of the categories (e.g. Horse riding).
Table 1
Descriptive Statistics for Athletes and Students
Athletes Students
Factor n % n %
Age 18-20 56 30.8 30 8.2
21-23 45 24.7 93 25.3
24-26 31 17.0 72 19.6
27-29 15 8.2 45 12.3
30-32 13 7.1 30 8.2
33-35 8 4.4 36 9.8
36 + 14 7.7 61 16.6
Previous experience with psychologist No 111 60.7 165 45.0
Yes 72 39.3 202 55.0
National or elite group Yes 138 75.0 - -
No 46 25.0 - -
Type of sport Racquet 24 12.8 - -
Precision 32 17.1 - -
Aesthetic 13 7.0 - -
Speed and conditioning 36 19.3 - -
Combat 25 13.4 - -
Power 22 11.8 - -
Other 35 18.7 - -
Note. University students were not assessed on sport specific factors, hence the dashed cells.
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 15
Prevalence
There was a significant difference in prevalence of clinically relevant anxiety symptoms
between athletes and university students [x2 (1) = 6.82, p = .009], with athletes reporting
significantly lower prevalence (20.2 %) than university students (30.7 %). Athletes reported also
significantly lower prevalence of depression symptoms (20.9 %) than students (34.1%) [x2 (1) =
10.26, p = .009].
The Effect of Participant Status and Gender on Anxiety and Depression symptoms, and
Help-Seeking Intentions.
Means scores for anxiety and depression symptoms, and help-seeking intentions by
gender and participant status are displayed in table 2.
Anxiety symptoms. There was a significant main effect of participant status [F (1, 538) =
14.20, p < .001, partial η2 = .03] and gender [F (1, 538) = 13.48, p < .001, partial η2 = .02], but no
significant interaction effect on symptoms of anxiety. Hence independent of participant status,
males had on average lower levels of depression symptoms than females, and independent from
gender, athletes had on average lower levels of depression symptoms than students. The total
model explained 6.3 % of the variance in anxiety symptoms with age significantly contributing
to the overall model [F (1, 538) = 8.91, p = .003, partial η2 = .02].
Depression symptoms. There was a significant main effect of participant status [F (1,
535) = 9.92, p = .002, partial η2 = .02] and gender [F (1, 538) = 9.12, p = .003, partial η2 = .02],
but no significant interaction effect on symptoms of depression. Hence independent of
participant status, males had on average lower levels of depression symptoms than females, and
athletes had on average lower levels of depression symptoms than students, independent from
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 16
gender. The total model explained 4.0 % of the variance and the age covariate did not
significantly contribute to the overall model.
Help-seeking intentions. There was a significant main effect gender [F (1, 532) = 9.02, p
= .003, partial η2 = .02], but no significant main effect of participant status or interaction effect
on help-seeking intentions. Hence independent of participant status, males had on average lower
help-seeking intentions than females. The overall model explained 12.0 % of the variance in
help-seeking and was significantly influenced by previous help seeking [F (1, 532) = 37.58, p <
.001, partial η2 = .07] and age [F (1, 532) = 12.89, p < .001, partial η2 = .02].
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 17
Table 2
Means and Standard Deviations and Sample sizes in Anxiety, Depression, and Help-
Seeking Intentions by Gender and Participant Status
Measure Gender Participant status N M SD
Anxiety symptoms Male University students 98 6.46 4.94
Individual sport athletes 85 4.94 3.93
Total 183 5.75 4.55
Female University students 266 8.13 5.22
Individual sport athletes 94 6.79 4.43
Total 360 7.78 5.05
Total University students 364 7.68 5.19
Individual sport athletes 179 5.91 4.29
Total 543 7.10 4.98
Depression Male University students 97 6.89 5.59
Individual sport athletes 85 5.48 4.22
Total 182 6.23 5.03
Female University students 265 8.44 5.42
Individual sport athletes 93 7.05 5.13
Total 358 8.08 5.37
Total University students 362 8.02 5.50
Individual sport athletes 178 6.30 4.77
Total 540 7.46 5.33
Help-seeking intentions Male University students 97 4.37 1.13
Individual sport athletes 85 4.21 0.97
Total 182 4.30 1.06
Female University students 262 4.77 1.09
Individual sport athletes 94 4.49 0.98
Total 356 4.69 1.07
Total University students 359 4.66 1.11
Individual sport athletes 179 4.36 0.98
Total 538 4.56 1.08
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 18
Moderating Effect of Participant Status on The Relationship Between Type of Symptom(s)
and Help-Seeking Intentions
Comparing female students and female athletes, there was a significant main effect of
symptom type on help-seeking intentions, [F (3, 342) = 2.98, p = .032, partial η2 = .03], but no
significant main effect of participant status. There was also a significant interaction effect
between type of symptoms and participant status on help-seeking intentions [F (3, 342) = 2.91, p
= .035, partial η2 = .03] (figure 1). This suggested that the relationship between symptom type
and help-seeking intentions was moderated by participant status among females. Simple effects
analyses showed that female athletes with only depression symptoms had significantly lower
help-seeking intentions (M = 3.60, SE = .32) than female students reporting only depression
symptoms (M = 4.77, SE = .19), [F (1, 342) = 9.69, p = .002]. The total model explained 9.1 %
of the variance in females’ help-seeking intentions with previous help-seeking [F (1, 342) =
16.73, p < .001, partial η2 = .05] and age [F (1, 342) = 8.82, p = .003, partial η2 = .03]
significantly contributing to the model.
No significant main or interaction effects were observed for differences between male
athletes and male students. However, previous help-seeking was a significant predictor of male
participants help-seeking intentions [F (1, 171) = 21.58, p < .001, partial η2 = .11].
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 19
Moderating Effect of Gender on the Relationship Between Type of Symptom(s) and Help-
Seeking Intentions
Comparing male and female students, there was a significant main effect of gender [F (1,
347) = 4.47, p = .035, partial η2 = .01] but no main effect of symptom type or interaction effect
between gender and type of symptoms, suggesting that help-seeking intentions were lower
among male than female students independent from symptom type. The total model explained
8.9 % of the variance in students’ help-seeking intentions with previous help-seeking [F (1, 347)
= 18.47, p < .001, partial η2 = .05] and age [F (1, 347) = 9.37, p = .002, partial η2 = .03]
significantly contributing to the model.
Comparing male and female athletes, no significant main effect of symptom type or
gender was observed. However, there was a significant cross-over interaction effect between
0,00
1,00
2,00
3,00
4,00
5,00
6,00
Female students Female athletes
Inte
nti
on
sco
re
Participant status
None Anxiety only Depression only Comorbid
Figure 1 Help-Seeking Intentions for Female Participants by Participant Status
and Type of Symptoms
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 20
type of symptoms and gender on help-seeking intentions [F (3, 166) = 2.84, p = .040, partial η2 =
.05] (figure 2). Simple effects analyses showed that female athletes with no clinically relevant
symptoms had higher intention scores (M =4.585, SE =.120) than male athletes with no
symptoms (M =4.205, SE =.114), [F (1, 166) = 5.29, p = .023]. A reverse effect was shown for
athletes reporting only depression symptoms, where male athletes had significantly higher
intention scores (M =4.41, SE =.32) than female athletes (M =3.47, SE =.29), [F (1, 166) = 4.76,
p = .030]. The total model explained 15,1% of athletes’ help-seeking intentions, with previous
help-seeking from a psychologist significantly contributing to the model [F (1, 166) = 19.34, p <
.001, partial η2 = .10]. The influence of age on help-seeking intentions did not reach statistical
significance.
Figure 2 Help-seeking intentions for athletes by gender and type of symptoms
0,00
1,00
2,00
3,00
4,00
5,00
6,00
Males Females
Inte
nti
on
sco
re
Athlete gender
None Anxiety only Depression only Comorbid
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 21
Discussion
This study aimed to assess differences in anxiety and depression symptoms, and help-
seeking intentions between individual sport athletes and university students in Iceland.
Furthermore, the aim was to extend the current athlete help-seeking literature by exploring the
relationship between symptoms and help-seeking intentions, and if gender or participant status
moderated this relationship.
The prevalence of clinically relevant symptoms of current anxiety was 20.2 % among
individual sport athletes, which was significantly lower than the 30.7 % prevalence observed
among university students. Athletes reported also significantly lower prevalence of depression
symptoms (20.9 %) than students (34.1%). Although athletes in this study had higher prevalence
rates than what has been reported in some previous studies among team sport athletes (Junge &
Feddermann-Demont, 2016), it is difficult compare these studies as different measures were
utilized to assess prevalence. Nevertheless, it is possible that the higher prevalence rate in the
current study compared to previous studies among team sport athletes reflect the notion that
individual sport athletes are more prone to CMDs than team sport athletes. For example, while
Junge and Feddermann-Demont (2016) reported lower rates of depression and anxiety symptoms
among soccer players, Hammond et al. (2013) showed similar rates of depression symptoms
among swimmers as the current study.
It was found that independent of participant status (i.e. student or athlete), male
participants reported on average lower anxiety and depression symptoms than females.
Furthermore, both male and female athletes reported lower prevalence than their student
counterparts. These results are in line with some previous studies suggesting males have on
average lower symptoms of anxiety and depression than females (e.g. Steel et al., 2014), and that
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 22
athletes may have lower prevalence of some CMDs than university students (Armstrong &
Oomen-Early, 2009) or other non-athlete populations (Armstrong et al., 2015). Although not
specifically addressed in this study, according to some studies, the observed differences in
prevalence of anxiety and depression symptoms could potentially reflect athletes’ higher internal
(e.g. self-esteem) and external (e.g. social support) protective resources gained through the
socialization in and through sports (Armstrong, Burcin, Bjerke, & Early, 2015).
As expected, male participants in this study had lower intentions to seek help from
psychologist than females, and is in-line with findings from previous studies (Addis & Mahalik,
2003). Based on the notion that socialization through sports could promote identification with
norms that may hinder athletes inclination to seek help for mental health problems (Gulliver et
al., 2012; Steinfeldt et al., 2009; Watson, 2005), it was expected that athletes would have lower
help-seeking intentions than university students. However, although athletes had on average
lower help-seeking intentions than students, this difference was not statistically significant.
An important aspect of the current study was however the idea, that help-seeking
intentions do not present themselves in a vacuum. Instead, help-seeking intentions may depend
on the type or severity of symptoms experienced by individuals (Rickwood et al., 2005). The
second aim of the study explored this argument and it was found that symptom type was
significantly related to help-seeking intentions among females, but not males. For females, the
relationship between symptoms and help-seeking intentions varied as a function of participant
status; female athletes who experienced clinically relevant symptoms of depression expressed
significantly lower intentions to seek help than female students with these symptoms.
Considering that conformity to traditional masculine gender norms may be more prevalent
among female athletes than female non-athletes (Lantz & Schroeder, 1999; Steinfeldt, Zakrajsek,
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 23
Carter, & Steinfeldt, 2011), it is possible that that the lower intentions to seek help among female
athletes than female students with depressive symptoms reflected this difference. For example,
female military veterans showed no differences from men in relation to attitudes towards seeking
psychological help in college after service (DiRamio, Jarvis, Iverson, Seher, & Anderson, 2015).
Hence, it is possible that due to their socialization through and in sports, female athletes in this
study identified more with norms discrepant with the act of seeking help than female students.
There was no significant main effect of symptom type on help-seeking when tested
within the student and athlete samples separately. However, there was a significant cross-over
interaction effect of gender and symptom type on help-seeking intentions among the athlete
sample. This suggested that the relationship between symptoms and help-seeking intentions were
different depending on athletes’ gender. More specifically, female athletes with no clinically
significant symptoms reported higher intentions to seek help than their male counterparts.
Furthermore, in athletes reporting clinically relevant depression symptoms, help-seeking
intentions were significantly lower for female than male athletes. Although no specific
hypotheses were set forth, this latter finding was especially surprising considering that males, of
different ages, ethnicities, and social backgrounds, have shown to be less likely than females to
seek help for different mental and physical issues (Addis & Mahalik, 2003), and that this
gendered help-seeking pattern has also been consistently reported within the athlete population
(Martin et al., 2001, 2004).
However, as discussed by Deane and colleagues (2010) while individuals with minimal
symptoms may initially report intentions to seek help in the future, as mental health symptoms
emerge, intentions to seek help may decrease (Deane et al., 2001). While female athletes without
clinically relevant symptoms reported higher willingness to seek help than male athletes, this
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pattern in help-seeking intentions was reversed when depression symptoms were clinically
relevant. Hence, for female athletes, the deliberate decision process to seek help (intention)
(Rickwood et al., 2005) may have been disrupted due to the type of symptoms they experienced.
Although the behavioral characteristics related to depression, such as decreased levels of interest
and energy, and increased hopelessness, may explain the negative correlation between
depression and help-seeking (Nam et al., 2013), it does not explain why depression symptoms
influenced female athletes intentions significantly more than those of males’. One previous study
among female university students has however found similar findings. Chang (2013) studied
help-seeking intentions for depressive symptoms among Chinese University students and found
that help-seeking intentions decreased as symptom severity increased. Interestingly, Chang also
found that gender moderated the effects of symptom severity on help-seeking, where females
with increasing levels of depression were less likely than male students to seek professional help.
These findings are intriguing and underline the importance of assessing individuals’ symptom
type and severity when exploring patterns of help seeking. Furthermore, although several studies
have supported the notion that males have lower help-seeking intentions than females, this
relationship may not be as straightforward as previously indicated. Hence, within some
population sub-groups such as athletes, females may be in an elevated risk for not seeking help
when levels of depressive symptoms reach clinical relevance.
The Icelandic version of the Beliefs About Psychological Services (I-BAPS), that was
utilized in the current study to measure help-seeking intentions is currently the only measure
about help-seeking intentions that has been adapted to the Icelandic context. In a study by
Ægisdóttir & Einarsdóttir (2012) the psychometric properties of the IBAPS was tested among
336 randomly selected, 17 to 70 year old Icelandic participants. When comparing the mean
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 25
scores from that study with the means in the current study, athletes and university students
scored similarly or slightly higher than the Icelandic general population. However, when
considering current symptomology, female athletes with depression symptoms had considerably
lower intention scores than the Icelandic female population. Therefore, it is important for the
local and national sport organizations, and other stakeholders developing support and prevention
strategies for in-risk athletes to be aware of the possibility; that although male athletes have been
previously identified as a risk group for not seeking help for mental health problems, female
individual sport athletes with depression symptoms may be an important risk group.
It is also worth noting that previous help-seeking experiences explained a significant
proportion of the total variance in all models, suggesting that previous experiences with a
psychologist may be a robust predictor of help seeking intentions among Icelandic athletes and
university students. This is in line with previous studies (Aegisdottir & Gerstein, 2009;
Rickwood et al., 2005) and underlines the fact that preventive efforts among athletes should
focus on introducing positive psychological experiences to athletes early in their careers in order
to lower potential barriers to help-seeking. Based on the current results, it seems that Icelandic
individual sport athletes have less experience with psychologist than university students. Future
studies should assess whether this pattern is the rule, rather than the exception within the athlete
population, and hence develop future youth and junior development programs accordingly.
There are some limitations to this study that should be mentioned. Firstly, the study was
cross-sectional in nature and hence causal attributions cannot be made. Furthermore, self-
selection bias due to the convenience sampling methodology could have influenced the results
and hence these results should be replicated in future studies with a more representative sample.
Furthermore, help-seeking from other sources, such as family and friends was not analyzed, thus
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 26
it is possible that female athletes with depression symptoms in this study were more likely to
seek help from these sources rather than from psychologists. Finally, although 75% of the
athletes reported being currently in an elite group or national team, and that top athletes in
Iceland were directly contacted through Facebook or through their coaches, it is difficult to
evaluate athletes’ competitive level in this sample. As discussed by Swann et al. (2015) the
competitive level may vary largely depending on type of sport and depending on its size and
popularity within the country.
Nevertheless, to the author´s knowledge, the current study is the first study to assess the
effect of anxiety and depression symptoms on help-seeking intentions among a sample of
athletes competing in a range of different individual sports. Furthermore, it utilized standardized
measures that have been adapted to the Icelandic context and hence provides a good basis for
future studies among the Icelandic athlete population. The comparison group consisted of
university students from all the seven Universities in Iceland. Considering that University
students have been shown to be an important population risk group, both in terms of prevalence
of CMDs (Stallman, 2010) and help-seeking intentions (Hunt & Eisenberg, 2010), this study may
provide useful information concerning the risk-status of Icelandic individual sport athletes.
Conclusions and future directions
This study provides preliminary findings among individual sport athletes in Iceland and
suggests that although athletes may have in general lower levels of anxiety and depression
symptoms than Icelandic university students; female athletes that do experience depression
symptoms may be in an increased risk for not seeking help from psychologist. Considering that
previous help-seeking was the strongest predictor of willingness to seek help from a
psychologist, it is important that local and national sport organizations, and other stakeholders
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 27
promote early contact with the psychology professionals. By introducing the different aspects of
psychological services and concepts as a normal part of the athletic culture, it is perhaps possible
to further promote help-seeking intentions and behaviors in the future. Future studies should
conduct longitudinal studies to describe the developmental features of CMDs and help-seeking
among athletes to identify relevant sport and non-sport specific determinants. Furthermore, more
studies are warranted to replicate the findings concerning the potential negative impact of
depression symptoms on female athletes help-seeking intentions.
Running head: ANXIETY AND DEPRESSION SYMPTOMS, AND HELP-SEEKING INTENTIONS 28
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